During an assessment of the cranial nerves, the nurse finds the following: Asymmetry when the client frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and an escape of air from the right side when the client puffs their cheeks. This would indicate the dysfunction of which of the cranial nerves?
Motor component of IV (Trochlear)
Motor and sensory components of XI (Accessory)
Motor component of VII (Facial)
Motor component of X (Vagus) and sensory component of XII (Hypoglossal)
The Correct Answer is C
A) Motor component of IV (Trochlear): The trochlear nerve primarily controls the superior oblique muscle of the eye, which is responsible for downward and lateral eye movements. The findings described do not relate to eye movement and therefore do not indicate dysfunction of this nerve.
B) Motor and sensory components of XI (Accessory): The accessory nerve innervates the sternocleidomastoid and trapezius muscles, primarily affecting head rotation and shoulder elevation. The symptoms noted in the assessment do not pertain to these muscle functions, so this option is not correct.
C) Motor component of VII (Facial): The signs of asymmetry in frowning, uneven eyebrow lifting, sagging eyelids, and air escaping when puffing the cheeks are characteristic of dysfunction in the facial nerve (cranial nerve VII). This nerve controls the muscles of facial expression, and impairment would lead to the described asymmetrical movements.
D) Motor component of X (Vagus) and sensory component of XII (Hypoglossal): The vagus nerve affects autonomic functions and some swallowing muscles, while the hypoglossal nerve controls tongue movements. Neither nerve is primarily responsible for the facial expressions described in the assessment findings, making this option incorrect.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
A) Idiopathic neuropathy has no known cause: This statement is accurate, as idiopathic neuropathy refers to nerve damage for which no specific cause can be identified despite thorough investigation. The term "idiopathic" literally means "of unknown origin," indicating that the underlying mechanism remains unclear.
B) Idiopathic neuropathy is hereditary in nature: While some neuropathies can be hereditary, idiopathic neuropathy itself is not classified as hereditary since it lacks a defined genetic cause. Hereditary neuropathies are specific types that have a genetic basis.
C) Idiopathic neuropathy is caused by nutritional deficits: Nutritional deficits can lead to various types of neuropathy, but idiopathic neuropathy specifically is characterized by the absence of a known cause. Therefore, attributing it to nutritional deficits would be incorrect.
D) Idiopathic neuropathy is caused by disease or illness: While certain diseases can cause neuropathy, the key characteristic of idiopathic neuropathy is that no specific disease or illness has been identified as the cause. This differentiates it from other neuropathies that are secondary to identifiable conditions.
Correct Answer is C
Explanation
A) "The client may be having a cardiac event": While this statement indicates a potential concern, it lacks specific details about the client's current condition. It suggests a possibility but does not clearly communicate the immediate issue or symptoms being experienced.
B) "The client needs an EKG. Please see her immediately": This statement expresses urgency and a request for action but does not provide the necessary context or information about the client's symptoms. It is more aligned with the "Request" part of SBAR rather than the "Situation."
C) "The client is experiencing chest pain and shortness of breath": This statement accurately describes the current situation the client is facing. It provides essential information regarding the symptoms the nurse is observing, making it a clear example of the "Situation" in the SBAR framework. This information is critical for the provider to understand the urgency of the situation.
D) "The client's admitting diagnosis is stage 2 breast cancer": While this statement provides important background information, it does not reflect the immediate situation that requires attention. It does not address the current health issue that is prompting the nurse to contact the provider.